Epidemic of fear?

Luc Bonneux and Wim Van Damme, in the new BMJ (off limits to commoners) offer a commentary entitled "An iatrogenic pandemic of panic." They mean to suggest that public health authorities have created such a pandemic by warning the public about the dangers of an influenza pandemic potentially arising from the current zoonotic of H5N1 avian flu. This parallels the dust-up which has been going on at Effect Measure between the proprietors and popular medical writer Marc Siegel, who in most public forums* seems to make approximately the same argument.

I have largely steered clear of this whole bird flu flapdoodle because others are on the case and my social science perspective hasn't really been what is at stake - at least until now. But I feel I should come out and let people know what I think about all this.

First of all, when Bonneux, Van Damme and Siegel actually try elucidate the nature of this devastating mass panic, it doesn't seem to amount to a whole lot. The sole definable ill effect seems to be that a few people are conniving to obtain oseltamivir (Tamiflu) to keep in the medicine cabinet against a rainy day, and the US and UK governments, and some other wealthy countries, are buying up modest stockpiles. There has also been a decline in poultry consumption in some places. It is true that both of these responses are probably inappropriate, however I'm not sure that it is reasonable to label them as "panic." Nobody can point to mobs rioting in the streets to get their allocation of Tamiflu, or terrified masses collapsing with palpitations at the sight of a chicken.

Another rather vague complaint is that pandemic flu preparation diverts resources from other public health problems such as HIV, malaria, waterborne diseases etc. which are already here. I must say there isn't any evident basis for this complaint - it's not as though there was any identifable money in the pipeline to address those problems which has been diverted to pandemic flu preparation. Most of the preparation that is happening -- which is very little indeed -- is essentially generic emergency preparedness which will be equally applicable to any widespread infectious disease emergency, and it is hard to see why anyone objects to that. There is a modestly funded program in vaccine research for H5N1 flu -- so far not very fruitful -- but that hardly seems objectionable either.

Now, just FYI, hording Tamiflu is dumb because a) it doesn't work very well, it only shortens the course of ordinary flu by one day; b) there isn't enough of it in the world to make much of an impact on a pandemic; and c) if there is a pandemic, and lots of people use tamiflu, there's a good chance that resistant strains of the virus will quickly emerge anyway. Also, hording results in misallocation. Rich people in rich countries get it, whereas if it's useful at all its in protecting frontline health workers to some extent so they get back on the job faster, which is really just to say, somebody else ought to be hording it in different places, for different purposes.

In the end, what people are really disagreeing about, when they pretend to be having some ill-defined ideological battle, is the actual probability of a major flu pandemic in the near future. Here, I'm not exactly an expert, but I'm pretty sure this is the correct answer: it is meaningless to try to assign a probability to this. It's a qualitative judgment.

We're still in the process of learning about the evolution of influenza viruses and the characteristics that make for easy human transmission and virulence. Based on what we know now, the virus that's circulating in birds right now has the kinds of characteristics that could lead to a 1918-type event. Such an event, in the modern world which has many times more dense centers of population, which are much larger; which has far more extensive and rapid networks of international commerce and travel; which has a far more complex and densely connected global economy; and which has a fragile international order; could be a big problem, cost a lot of money, cause a lot of disruption. It would be irresponsible not to imagine such a possibility and try to prepare for it. Nobody can say "there's a 64.3% chance it will happen before September 1, 2008," or "There is less than a 19.5% chance." Nobody knows. But it very well might happen and it would be foolish to pretend otherwise.

Now, people may well exploit fears and various scenarios, likely or unlikely, for ill purposes. For example, Mr. Bush's first reaction, on learning of the possibility of pandemic flu, was to talk about making preparations for mass quarantine and martial law. But that's because he's a malignant clown, it's not reflection on the virologists who drew attention to the possibility of a pandemic. The Emperor Chimpoleon has exploited other fears for malevolent purposes as well, but that doesn't mean that anybody who talks about proliferation of dangerous weapons is being irresponsible. Scientists and public health authorities who work in this area have a duty to inform the public of their findings and concerns, honestly and directly. Other people in authority, and the news media, have responsibilities pertaining to how they respond, which they may or may not discharge appropriately. That's on them.

*(Latin pedantry alert: "forums" is now the standard plural form in English.)